Population health and wellness professionals segment populations to provide targeted interventions with the aim of achieving health as defined by the World Health Organization (WHO): “complete physical, mental, and social wellbeing.” They analyze data, considering multiple health determinants such as:
Along the way, population health and wellness practitioners discover ways to improve the healthcare system, better neighborhoods, and engage individuals. The Centers for Disease Control and Prevention provides training to help individuals improve their population health skills.
Population health involves healthcare organizations, community agencies, and wellness companies working together to improve determinants of health with the aim of improving the health and wellbeing of groups of people.
Public health concerns itself with protecting everyone’s health through research, public policy and legislation, education, and social change. These efforts result in less injury and disease, improved health, and lower mortality rates for countries and communities. Examples include healthier built environments, reduced noise pollution, increased access to healthy foods, and effective vaccination programs.
Community health is a subset of public health that focuses on designing and implementing innovative programs that improve the health of specific communities, grouped by geography or based on race or ethnicity. Local agencies, tribal organizations, governmental entities, schools, and non-profits work together to reduce disease and create healthy communities.
Population health management (PHM) is a strategy primarily used within health and wellness industries to improve health outcomes of specific groups of people. It includes data collection and analytics, risk stratification, care management, engagement, interagency coordination, and outcomes measurement. PHM allows health and wellness professionals to prevent disease, plan treatments and interventions, contain costs, and improve quality of life through multiple touchpoints, including clinical settings, community agencies, and lifestyle management. At times it requires complex care plans that help care managers engage with individuals within targeted populations. Population health tools such as electronic health records and health risk assessments help inform population health companies and practitioners of current health status, risk of future disease, lifestyle behaviors, change readiness, outcomes, and more.
Efficient, effective population health depends on data that is managed by information technology (IT). It should be no surprise, then, that the essential tools for population health companies and other population health professionals include health IT tools:
Many of these essentials were identified by the Patient-Centered Primary Care Collaborative in their October 2013 report. Population healthcare has the added layer of communication systems that connect entities within the healthcare and health plan system that allow them to track referrals, monitor hospital readmissions, manage claims, and interface with extended care facilities.
Data: Population health requires data – both objective data (e.g., personal health history, claims data, and social determinants of health like zip code and income) and subjective data (e.g., happiness, pain, intake of healthy foods, coping, and readiness to change). Data collection also requires an inward look. What resources are available to maximize population health? And what is lacking that could hamper those efforts
Technology: Technology is essential for effective population health programs. Population health and wellness professionals need a way to collect data, a place to store the data, the ability to securely share data (thanks to the patient access and interoperability mandates by the Centers for Medicaid & Medicare), and a method for analyzing the data and turning it into something useful for positive change. The future of healthcare data analysis may lie in the merger of consumer data and health data—made possible by technological advances. Looking at consumer data helps population health and wellness professionals devise care plans and interventions that fit their population’s engagement style. In addition, intelligent analytics that integrate “soft data” such as chart notes can define actionable steps designed to overcome impediments. Actionable analytics (links opens as PDF) can identify high risk individuals who are most likely to benefit from care plans, as well as the kinds of interventions most likely to succeed. Many interventions will also use technology, such as telehealth, portals, trackers, and email reminders, although some populations need high-touch services, such as in-home visits.
Plans and goals and collaboration: Population health and wellness managers must have solid plans and goals – both short- and long-range – grounded in strategic decisions made in collaboration with healthcare entities, neighborhood groups, community agencies, and government organizations. What will be the priorities for the next quarter, next year, and 5 years down the road? How will success be measured? What will it take for participants to buy in and engage? Positive change is slow to impossible when individuals don’t participate in their health. But a social norm where people are both interested in their health and feel empowered to actively participate in healthful behaviors—such as being physically active daily and eating healthful meals—can create an atmosphere of change. The key is getting individuals to see themselves as active participants in their health and longevity.
For population health and wellness managers
A health risk assessment informs population health programs. It gives health professionals an honest look at their population’s current health practices and risk of future health problems. Armed with that information, they can identify and segment individuals who are at greater risk for future (and often costly) chronic disease and then implement strategies that can promote positive lifestyle choices and improve determinants of health. Follow-up assessments reveal whether the changes have impacted health trends.
Most health risk assessments include a personal report with analysis of current health and recommendations for each participant which, if followed, should improve health over time.
A health risk assessment (HRA) should ask questions to determine current health and happiness, such as height and weight, mood, personal health history, and current treatment. It should also collect information on an individual’s health habits, such as physical activity, stress, social support, diet, sleep, change readiness, and whether they are current with recommended exams and vaccines. This helps to predict risk of future health problems. A robust HRA will also ask about income, education, accessibility, and history of trauma.
Population health and wellness professionals should evaluate the effects of their initiatives. One way to receive a tangible measurement is to administer a health risk assessment annually and compare prior assessment results with the current results. There should be improvements in health practices and, as a result, improvements in health and quality of life. As diseases are managed, averted, or reversed, there should be lower rates of hospitalizations and urgent care visits. Employer groups should see higher productivity and job satisfaction.
IT (information technology) may well be the panacea for population health. Data is predominantly housed, exchanged, analyzed, and consumed electronically. Health and wellness professionals, faced with mountains of data, increasingly rely on population health IT to parse and digest data in innovative and efficient ways that allow them to efficiently identify risks, target interventions, increase engagement and behavior change, and achieve desired outcomes with minimal expense. The magnitude of data will continue to increase as Baby Boomers age. By 2029, one in five Americans will be 65 or older. Population health IT innovations accommodate both the numbers of people and the discrete data bits required for personalized care. Douglas B. Fridsma, MD, PhD, FACP, FACMI, president and CEO of the American Medical Informatics Association (AMIA) observes that population healthcare managers “need to use technology and clinical research to take our interventions up a level of magnitude to a population of 1 to 2 million—or even, when we get this right, a population of billions of people.”
In addition, the Centers for Medicare & Medicaid (CMS) has joined forces with the Office of the National Coordinator for Health Information Technology (ONC) to support seamless and secure interoperability. Health IT professionals are valued members of population health teams and wellness and population health managers work toward open, yet secure, nationwide connectivity.
The Health IT Playbook by the Office of the National Coordinator for Health Information Technology is filled with tips and best practices to help health professionals optimize their use of health IT for their population health efforts. The playbook emphasizes the importance of privacy and data sharing. Application Programming Interface (API) calls are a type of integration that allows for secure information exchange between electronic health records (EHRs) and other data systems, such as a health risk assessment or patient portal.
Because population health and wellness delves into the realms of health care and personal information, professionals are bound by laws and regulations designed to protect privacy. These include the Health Insurance Portability and Accountability Act (HIPAA), the Affordable Care Act (ACA), Centers for Medicare & Medicaid Services (CMS) policies to improve patient access, and Health and Human Services rules to improve interoperability of electronic health information and care coordination throughout the healthcare system. Other laws and regulations come into play when working with special populations, such as the Genetic Information Nondiscrimination Act (GINA) when working with employee groups, the Annual Wellness Visit requirement for Medicare, NCQA Health Plan Accreditation standards and Healthcare Effectiveness Data and Information Set (HEDIS) measures, and state or local laws.
Having a solid strategy can improve the success of population health efforts. Population health and wellness professionals should take the lead in learning as much as possible about each population to establish a baseline and inform future actions. Assembling a team of interested, committed individuals, such as clinicians, community influencers, technology experts, and government representatives, can make data collection easier as long as they are willing to share their data. Interoperability regulations aim to make this step much easier.
Useful data to consider includes stats on safety, greenspaces, walkability, housing, transportation, disease prevalence, access to healthcare services, alcohol and tobacco use, unsafe sex, health habits such as diet and exercise, education level, employment, social support, cultural beliefs, technology skills, psychographics, and self-reported change readiness. As population health and wellness professionals dig into the data they can both target high risk populations and identify which things are most impactful on the wellbeing and quality of life – both protective and harmful – of their populations. The Commonwealth Fund developed personas for high-need, high-cost patients that can help with population health efforts. It’s then time to design an action plan. Interventions to achieve optimal health may include healthcare pathways and protocols, changes to infrastructure, community programs or classes, or legislative changes.
Population health and wellness strategies prevent disease, increase quality of life, and improve health outcomes. A presentation at a 2016 HIMSS conference quantified the return on investment of population health solutions for chronic conditions such as diabetes and psychological distress. Quantifying a hard-dollar return on investment (ROI) based on disease prevention, management, or reversal can be complicated. But there is another metric that clearly shows the value of population health and wellness. Value on investment (VOI) considers longevity, increased function, improved quality of life, reduced readmissions, fewer sick days, enhanced compliance, improved self-assessment of health, and overall life satisfaction. In their Program Measurement and Evaluation Guide, the Health Enhancement Research Organization (HERO) and Population Health Alliance (PHA) recommend workforce wellness programs report “impact on lifestyle-related health risk factors.” When calculating the value of intervention efforts, population health and wellness professionals should measure both ROI and VOI.
The choice between building or buying software is a decision many executives may have to make. This same question often exists for health risk assessments (HRAs) too.
In this guide, we look at some of the factors typically evaluated when deciding between buying and building an HRA
The aim of the CMS patients first initiative is to empower patients to be active participants in their health and wellbeing. This requires accessible, high quality, and affordable healthcare services and interventions. Recent examples of patient-focused population health efforts include improved health outcomes for Hispanic Americans and greater understanding of the unique needs of sexual and gender minorities. These accomplishments result from increased understanding of diversity, identifying barriers, increasing transparency, and using data to inform strategies for optimal health outcomes. Some health professionals are participating in a pilot program that gives patients an even greater voice. Called OneNote, the program invites patients to not just read but to contribute to notes in their medical records.
When workforce wellness began, it was primarily focused on encouraging people to lose weight, quit smoking, and exercise – with the aim of reducing absenteeism and boosting productivity. Today’s workplace wellness models encompass employee quality of life – a comprehensive employee health management approach. Most workforce wellness programs use a health risk assessment, often administered by a third party, such as a wellness provider or health plan. A population health or wellness professional will analyze the data to determine which interventions will be most beneficial for achieving multiple goals, such as improved health, disease prevention, increased employee morale, mental health, reduced healthcare costs, greater loyalty, and increased productivity.
Wellness initiatives include on-site wellness clinics offering vaccinations or urgent care services, fitness centers, rooftop gardens that supply healthy foods in the lunchroom, financial wellness counseling, nap pods, mental health days, and a culture of wellbeing. Along the way, they measure success. While some workforce wellness programs see a return on investment in the first year, year one often results in indirect benefits. HERO and PHA recommend the following core metrics: financial outcomes, health impact, participation, satisfaction, organizational support, productivity and performance, and value on investment.
According to Dr. Brittany Carter, Director of Health and Research at Wellsource, “Precision medicine is an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.” It’s a term often interchangeable with personalized or individualized medicine since it involves tailoring health care to an individual based on their unique characteristics. Population health and wellness professionals spend much of their time strategizing how they can improve the quality of life for segmented populations. Yet it is individuals who make up those groups. Increasingly, population health and wellness professionals turn to a precision medicine approach to disease management and prevention. The ability to consider genetic differences and how genes impact environmental and lifestyle factors allows for finely tuned interventions that improve positive outcomes. Data and technology bring it all together. The nationwide, million-volunteer, longitudinal All of Us Research Program is actively researching a wide variety of health conditions to see how “individual differences in lifestyle, environment, and biological makeup can influence health and disease.”
Effective population health requires collaboration between multiple entities. Of course efforts will include health providers, insurers, and social service networks. Who else will be an effective partner to work toward optimal health and wellbeing in targeted populations? Here are a few stakeholders to consider: pharmacies, schools, manufacturers, faith leaders, neighborhood associations, community action groups, clinics, IT companies, consumer marketers, software developers, health risk assessment vendors, dieticians, construction companies, researchers, business owners, farmers, government agencies, and politicians.
When considering what population health tools to use, be sure to include health risk appraisals. Also called health risk assessment or HRA, a health risk appraisal gathers a lot of data that can help inform population health and wellness strategies. For example, learning about an individual’s outlook on the future, how much pain they feel, or whether they have a social network can identify psychological distress. Seeing their health habits, such as how many hours they sit and whether they eat too much salt or saturated fat can help predict health problems. Knowing what unhealthy conditions individuals are ready to change helps professionals guide populations into targeted interventions that have the highest likelihood of success. Intervention efforts can have even more impact when population health and wellness professionals use a health risk assessment that allows data to be pulled seamlessly into an electronic health record or other secure data analysis system. Managed care plans are enhanced when HRA data is analyzed in combination with claims and social determinants of health data.
Sometimes defining populations and identifying interventions can be a lot easier than earning engagement in population health programs. Population health and wellness professionals must take steps to engage with people as individuals, not just with the collective community. Companies like TriHealth and Welltok have turned to consumer data, using mining methods commonly used in marketing to discover better ways to engage with individuals within their populations. Artificial intelligence, such as machine learning, and other technological advances can make it easier to integrate and analyze large data sets from disparate sources efficiently and effectively.
Care should be taken to connect with the most vulnerable and underserved populations. The American Journal of Managed Care identifies five vulnerable populations: chronically ill and disabled; economically disadvantaged or homeless; rural or geographically isolated; minorities such as the LBGTQ+ population; and children and older adults. Examples of underserved populations include migrant and seasonal farmworkers and urban-dwelling elderly.
Trust can be built by taking time to hear individual concerns and perspectives. Strategies and methods can be adapted as needed after population health and wellness professionals understand community nuances, best methods of communication, health literacy, and logistics of hard to reach populations. A health risk assessment that asks about change readiness is also useful for helping plan needed behavior changes that individuals are actually interested in pursuing.
Everything you need to engage your population from the start including: